Tuesday, July 31, 2012

After all it's not every day you see an internist who still frequents a hospital. We've known each other for years and he's been watching the changes in health care, too.

"Boy, they're really not happy Over There. Seems they've contracted with Big Boy insurance as part of their new ACO model. Everyone's going to get their piece before the doctors: Over There hospital, their four million administrators, lawyers, grounds crews, parking staff.... Then, after everyone else is paid, the doctors might get a few scraps if there's some left over. No guarantees. All risk, no certainty of reward. There was no way I could still go there. I joined them, but had to leave when I saw how unworkable that was."

"Isn't this our new way forward?" I asked.

"I guess so. Scary. But I've got just a few more years. Just have to get the kids through college."

There are those who will call this doctor's statement a veiled threat. Perhaps it is. Maybe economic times will make it difficult for many physicians to leave the security of their workplace in the upcoming years, but we should not take this doctor's comments lightly. There is an aire of uncertainty, and with it, anxiety. Doctors, like every person working today, are under growing financial pressure. But unlike every person today, they are saddled with unique physical, emotional, and legal threats, and it is no wonder many will leave the field for other endeavors if it's not worth it to stay.

Thirty percent of all of today's doctors are over 55. Most of these doctor just want to get their kids through college.

What happens then is anybody's guess, but one thing's for sure: these resourceful individuals aren't likely to be left holding the financial health care bag.

And with them will depart important leaders for our younger generation of doctors in medicine.

Sunday, July 29, 2012

There is a moment in everyone’s life, for oneself or a loved
one, when one receives the “Diagnosis.”
In that moment, eyes meet across the desk and the shell-shocked
individual looks up and asks, “Doctor, what should I do?” In that instant, the patient is putting all
of their trust in another human being who is trying nothing less than to save a
life.

A good doctor has always been a person who has the ability
to think autonomously and critically while holding themselves responsible for
the accuracy of their decisions. They
develop their own inner authority and autonomous thinking through years of
being scrutinized and challenged through training and exposure to an infinite
variety of clinical scenarios – many of which remain unique (despite what the
Internet would have us believe). It is
this collection of attributes that a patient relies on during that very critical
human-to-human moment.

But in the world of unintended consequences of health care
reform, we are systematically dismantling this kind of doctor. We are systematically diffusing
responsibility across care providers, undermining treatment authority,
dismantling critical thinking and derailing physicians’ moral authority.

Enter the era of Dr. McQueary.

At water-cooler talks and cocktails across the land in the
wake of the announced sanctions against Penn State, people are still asking how
a young coach Mike McQueary, brought up in a corporate, big-money team-think approach of
college football, could bear to witness the violation of a 10-year old boy in a
shower by his colleague and not rush to the child’s aid. Instead, at that moment he chose to walk away
to ask his father and the head coach what he should do. You see, there is no "I" in "team."

Would a patient in the throes of life-altering decisions want
a doctor with such team-think mentality as their doctor?

This is the precisely the right question to ask if we have the patience
to do so. Is the creation of doctors like this our intention? Must we believe the narrative of necessity and
progress that leads us to accept such a loss? It is a familiar individual vs. collective,
relationship vs. system debate. Yet this
time the debate is in an arena that has only the stakes of our mortality. Is this worth thinking about?

Dare we ask what we are creating as we move to make doctors
shift-workers, business minded. algorithm-driven, group-think,
productivity-incentivized cogs in our new heavily-funded health care wheel. Paying doctors for performance standards based
on computer-driven check-boxes, guideline adherence and proscribed health care
is of more importance than the individual.
Health care, then, devolves to nothing more than a nine-to-five series
of clicks.

Thursday, July 26, 2012

Doctors wanting to determine a patient's atrial fibrillation burden have a myriad of technologies at their disposal: 24-hour Holter monitors, 30-day event monitors that are triggered by an abnormal heart rhythm or by the patient themselves, a 7-14 day patch monitor that records every heart beat and is later processed offlineto quanitate the arrhythmia, or perhaps an surgically-implanted event recorder that automatically stores extremes of heart rate or the surface ECG when symptoms are felt by the patient. The cost of these devices ranges from the hundreds to thousands of dollars to use.

Today in my clinic, a patient brought me her atrial fibrillation burden history on her iPhone and it cost her less than a $10 co-pay. For $1.99 US, she downloaded the iPhone app Cardiograph to her iPhone.

Every time she feels a symptom, she places her index finder over the camera on the phone, waits a bit, and records a make-believe rhythm strip representing each heart rhythm. With it, comes the date and time. When the rhythm is in sinus, she learned that her heart rhythm was typically in the 60's at rest:

When the rhythm was in afib, it was considerably higher and sometimes displayed an irregular rhythm:

or sometimes it displayed an error message:

I got a relative picture of how often she was having afib and she got the opportunity to help me with her care.

Was this a medical device? No, it was an iPhone app.

Was it perfect? No it wasn't. I certainly couldn't differentiate frequent PAC's or PVC's from atrial fibrillation reliably. It was NOT an EKG after all. But we were past that point in her evaluation. I just needed to know how often she was having her known paroxysmal atrial fibrillation and she wanted to keep a convenient record of her episodes.

Was it helpful in this case? Absolutely.

More importantly, she just saved herself and the health care system a ton of money.

Welcome, my friends, to the era of patient-empowered, individualized medicine and a whole new era of patient care. Now, if we can just keep the FDA from screwing things up.

-Wes

PS: I have no commercial interest in the Cardiograph app and do not endorse it as a standard of care, but merely use this case to demonstrate how innovation can facilitate cheaper, equally-effective health care in some cases. I'd also like to thank my patient for allowing me to use her screen shots.

Tuesday, July 24, 2012

If you want to succeed in academic cardiology, get a federal grant for research.

Better yet: get a few well-paid industry grants, too.

These days lower-paid academic cardiologists are finding it tougher to find protected time for research and speaking because grants are harder to come by and money from their academic center is getting tight. For instance, the National Heart, Lung and Blood Institute (NHLBI) of the NIH no longer accepts investigator-innitiated innovative research grant program (R21), which was an important source of funding for researchers and has cut funding lines for established research funding grants (R01) from 15% to 10% acceptance rate. Medical device and pharmaceutical are also feeling the financial squeeze from diminished demand for their devices and boutique drugs (not to mention higher fees for the right to sell them in the US marketplace). Even worse, the federal government has less need for innovation in cardiology now but more need for "demonstration projects" for health care reform.

It's hard to write passionately about health care reform when your real gig is writing about cardiovascular drugs or devices.

And cardiology is still a procedural field that pays hospital systems pretty well. This presents another tough reality for academic cardiologists: they have to generate revenue somehow. Cash-strapped hospitals across the country are looking at challenged bottom lines. They are turning the heat on their revenue pipelines - all of them. Since cardiology is one of those pipelines, the days of stroking one's chin while researching sarcomeres has quickly evaporated to clinical productivity clauses.

And for academic cardiologists once content to research and pontificate on treatment strategies, they are learning the cold, hard reality that speaking gigs and guideline writing doesn't generate revenue for their center.

But there's still an out - a way forward for academic cardiologists everywhere, if you will.

In the increasingly competitive and evolving health care markets of America, there is a need for brand name doctor-managers: folks with marketing marquis value can drive clinical referrals to more clinical centers while serving as intermediaries between hospital administrators struggling to mesh newly hired cardiology groups with their former core cardiologist-employees. How successful these poster-children for health care innovation will be in their newly-created positions remains to be seen, but the demand is there and the migration's on. Lucrative pastures await for fairly low-paid academic cardiologists as health care consortiums grapple for ways to differentiate themselves from their competitors.

So like the mice in "Who Moved My Cheese," academic cardiologists are beginning to make their move and no ivory-tower academic medical center is safe.

Sunday, July 22, 2012

This morning's lead editorial in the Sunday edition of the New York Times was entitled "A Formula for Cutting Health Costs" and contained the byline "Alaska natives have something to teach doctors and patients in the rest of the world."

I read the editorial with interest, hoping that a new perspective, vision, idea, or insight would be mentioned that would provide a sustainable cost solution to our health care crisis in America. After all, America desperately needs solutions to this conundrum.

We learn in the editorial how the Southcentral Foundation in Anchorage, Alaska treating rural patients " has achieved astonishing results in improving health of its enrollees while cutting costs in treating them."

Sadly, cost saving information was not provided.

Instead, we read that "such a transformation would require upfront financing for training, data processing and the like, but the investment should (emphasis mine) rapidly pay off in reduced costs."

The article states that because of their efforts, "emergency room use has been reduced by 53%, specialty care visits by 65% and visits to primary care doctors by 36%." The editors claim "these efficiencies have clearly saved money" while saying in the same breath that spending of hospital services grew "by a tiny 7%" and its spending in primary care grew by 30% . How do they explain this growth as cost savings in the editorial? They do so by claiming that 30% growth was "still well below the 40% increase posted in the national index issued by the Medical Group Management Association."

But revenues grew too - substantially. According to Southcentral Foundation's own press release, "total revenue has consistently increased from $120.2 million in 2003 to $201.3 million in 2010, exceeding the Medical Group Management Association (MGMA) 90th percentile in 2010. Third-party payer revenue increased from $7.4 million to $17.9 million in the same time period, also exceeding the MGMA 90th percentile in 2010."

In truth, cost of care was not reduced nor was the quantity of care. What we actually have learned is the health care bill in Alaska has continued to grow at a pace that outstrips inflation while the editors of the sit back in their eames chairs and want to teach doctors a lesson.

After all, is is clear that the editors feel doctors are the problem. To the editors, doctors are the disdainers, loomers, and miscreants who must be given no place "to which they can retreat." Instead, if one is to believe the tone of the article, health care providers are optimally corralled, viewed in the open, and perhaps supervised by a lifeguard with a whistle. In the same breath the authors recommend establishing "trust and long-term relationships between patients and providers." This sounds nice until one realizes trust and long-term relationships between the patients and providers will be built (in their view) by "data mall" graphics that spur the "laggards" into compliance.

The editors continue with their scolding, pernicious nanny-state view by criticizing other providers and health care organizations who can't "summon the energy to transform their operations" to the Utopian vision put forth by this piece.

Perhaps most concerning for physicians is the sinister undertone that is becoming increasingly prevalent in some circles of main stream media. Presently doctors are facing huge cuts to their pay as part of the health care reform efforts underway. If the public is going to accept this as best for their own interest, then the editors have firmly established that physicians and hard working care providers are going to have to be subtly and constantly denigrated.

It is a shame that our health care reform discussion has come to this. Rather than enlisting physicians as part of the solution, we're now the problem.

Remember that when you can't get an appointment.

-Wes

Addendum 0912 am 23 Jul 2012:

Thanks to those that sent on these other examples of ongoing denigration of physicians:

Tuesday, July 17, 2012

Much of this is not residents' fault. They only have so many hours in so many days to attend lectures while caring for patients. Thanks to residency work-hour restrictions, those hours have become even fewer. To make matters much worse, through the year residents are torn to different rotations at different times and different hospitals. Since topics for EKG interpretation span over many lectures, it is impossible for residents to attend every lecture over the academic residency year. Just like when a student misses half the lectures for a college course, it's hard to get an A.

Yesterday, I stood before a crowded room of about 35-40 residents and interns for their first of many EKG classes. There they sat, with their nicely pressed florescent-white lab coats ready to learn. They were quiet and respectful as they sized up their middle-aged physician attending who apologetically arrived 5 minutes late after seeing an urgent consult in the Emergency Room. They had no idea what to expect. I some ways, neither did I.

I plugged in the obligatory USB thumb drive to the obligatory computer to display the obligatory Powerpoint presentation, then stopped. Up came the image on the screen. They turned toward it, oblivious how uninterested I was in the contents of the slide. I asked them a question.

"How many of you don't know the first thing about an EKG?"

Their heads swung back to me, silently. Much of the room smiled, not certain where I was going. Hesitantly, a few hands rose in the air.

I had never seen this before. As their soon-to-be instructor, I could not help but ask myself silently what the heck these kids have spent at least $200,000 of their parents' money learning in medical school. How on earth can any student leave four years of medical school education and not know the first thing about an EKG?

I pressed on.

"How many of you know something about an EKG and its basics but realize you need to know more?"

Relieved, I saw many more hands go up.

EKG reading is one of those basic skills that every physician should at least have a rudimentary knowledge. Medical school's controlled classroom-like environment lends itself better to instruction of the basics rather than hurried clinical rotations. Clinical rotations are where residents should fine-tune their skills in this area. How and why some medical students are not even exposed to this basic skill before entering their internship is one question, but what these young doctors are receiving for their huge costs of education is even a more important one.

As pressures continue to mount on physician salaries in the years ahead and their corresponding debts mount, perhaps we should ask ourselves why our young doctors continue to pay huge sums for their medical education of when the quality of the instruction has been allowed to slip to this level.

Could it be their academic instuctors never attended an EKG class either?

Friday, July 13, 2012

We sat in the dining room, catching up on the week's events. My colleague, ever insightful, turned to me and said, "Wes, as you know, I'm a regular reader of your blog but, dang, it sure has been depressing to read lately."

But someone has to tell these stories. They are important. As doctors who directly deliver health care to our patients, I believe that it is important to remind people that the Utopian vision for medical care that is being created is still not perfect despite how it's being sold to the public. Admittedly, it wasn't perfect before either and it needed to be changed. But as we move forward, all of us should appreciate that there are trade-offs in many of the so-called electronic and practice "efficiencies" and "requirements" that are being bestowed upon doctors today. I worry that too often, online doctors are so concerned how they are perceived publically that few dare speak out when things are amiss. In essence, the permanence of the online world paired with sounding too adversarial, coerces doctors to become forever politically correct. We should not underestimate the problems for doctors as they progress professionally when they go against the grain. We walk a very thin line. My hope, of course, is that with real live discourse on this little blog, our central planners of our next New World of health care might stumble upon our thoughts and at least consider the unintended consequences of their actions and (who knows?) move to improve the status quo. Doctors must be part of the solution after all.

So have a nice weekend. Realize that I really do love my patients and my job. Understand that I am sensitive to sounding too negative, but also know that I'm callin' 'em as I'm seein' 'em, and I'm definitely not making this stuff up.

Wednesday, July 11, 2012

In a provocative piece in the Journal of the American Medical Association (JAMA), Elizabeth Toll, MD pens a powerful portrait of what the Electronic Medical Record have brought to the doctor-patient relationship, describing both its benefits and its limitations (be sure to see the 7 year-old's precient drawing as well). Perhaps most disturbing was this passage in her essay:

There is a certain irony to all this. For years, we’ve been hearing that focusing on our patients as people, improving communication, admitting mistakes, and creating patient- and family-centered care will make us better physicians, gratify patients, and prevent lawsuits. In fact, professionalism and communication are core components of the residency training curriculum. Medical schools have begun to insist that applicants demonstrate proficiency in the humanities and social sciences, as well as the traditional hard sciences. So, to watch these directives shift with the mandate of the EMR seems a sad reversal of progress and common sense.

All this is not lost on our patients. In addition to the young artist, whose drawing speaks volumes, wherever I go in or out of the medical world these days, I hear patients' observations: “My doctor hasn't made eye contact with me since he got on that computer—he's not a very good typist.” “Our visits are rushed. My doctor used to have time to listen to my concerns, but now she spends a lot of time complaining about how hard her workday is.” Physician colleagues pour out similar comments: “In the past I would see a patient, write a note, close the chart, and spend a moment reflecting on the visit. Now my time goes to fighting with the computer and chasing down my colleagues to get them to lock their notes, so we can submit bills.” “I feel pulled in so many directions, like my brain is scattered. I went into medicine to work with people, but now I’m in front of a computer screen all day, managing systems. I still love my patients, but I hate how I’m spending my time.”

This essay has not been lost on the Electronic Medical Record industry. They are feeling the pushback of doctors who are insisting not just more information, but better information and better efficiencies. In a phone interview, Dr. Toll took some of these concerns further:

The EMR was designed to demonstrate the pieces of the record that you have to attend to in order to bill at a certain level. If you just enter a few questions and you only enter part of the exam, and you only add medicines and you only do this or that, you can only be reimbursed a certain amount. But if you asked about, for instance, the family history, the surgical history and the social history, then you have all the elements to charge more. So there’s an incredible temptation to just push, push, push and bring forward everything from the previous notes without re-asking the questions.

This creates a huge problem: The records are full of lies. They’re full of things that [physicians] have said they’ve done but truly haven’t. The patient has been in eighth grade for three years. The patients are divorced, but in the record they’re still married. The patient used to work as a nurse and now works as a librarian, but it hasn’t been changed in the record because people are giving quick, push-button answers to save time, and they don’t update the info. You can see this as you go through small things in the social history but also in [clinical histories]. Yesterday, someone sent me a letter about an amputee patient he sent to a podiatrist. He got a report back on both the patient’s feet. This patient only has one foot.

Cut and paste has its efficiencies and its downfalls. When audits happen to justify billing and innacurate copied paragraphs are found to fill the doctors' note, how will hospital systems respond?

Monday, July 09, 2012

Courtesy of the June, 2012 issue of the J Am College of Cardiology, I give you this fascinating case report of a suicide attempt using 6 ingested cylindrical AAA batteries that created, literally, an injury current on the patient's surface EKG:

Addendum 10 JUL 2012 14:15 PM CST:
This EKG probably warrants a letter to the editor of JACC. First of all, as has been pointed out by several individuals on Twitter (thanks @mzkhalil and @tobymarkowitz), it would be unusual for DC current to affect only the ST segment of the patient's EKG. Other causes of these findings include hyperventillation syndrome, coronary vasospasm (though this is usually associated with chest discomfort) or CNS disease to the EKG findings of an acute injury pattern, neither of which were discussed as possible causes for the findings, rather than a direct cause-and-effect of DC current from ingested batteries.

Sunday, July 08, 2012

While health care reform has benefitted large health care systems, it continues to decimate small practice physicians. This portends an ominous outlook for health care in small-town and rural communities. From Medscape Cardiology (registration required):

One third of physicians in small group practices who responded to a recent survey expect their 2012 income to fall below what they earned last year. Financial pressures could have a devastating effect on physicians in practices of 10 or fewer participants: 26% surveyed said they might have to close their practice within the next 12 months.

"The survey was emailed in April to a random selection of 15,000 of the 200,000 physicians who are registered members of MDLinx, a medical news website, and 673 responded," a spokesman told Medscape Medical News.

A total of 49% of small practice physicians reported cutting staff and services to reduce operating expenses. Despite such measures, 23% said they have used personal savings, and 20% have had to borrow money to cover expenses.

By comparison, only 13% of physicians at larger practices or hospitals expected their income to drop this year."This poll is quite startling in the revelations about small practices, the healthcare lifelines to many communities," said Stephen Smith, chief marketing officer for MDLinx. "Physicians have had missiles raining in on their practices at an increasing pace—the economy, regulations, paperwork, insurance, lawsuits, etc."

Thursday, July 05, 2012

A little box pops up before him asking if he asked the patient about the exercise. He mumbles something under his breath, clicks a little box beneath the question, then moves on.

This is what medicine has become: a series of computer queries and measures of clicks. It must be measurable, quantifiable, and justifiable or it didn't happen.

Do they ask if I asked them about if they used cocaine? Of course not: too politically incorrect.
Do they ask if I really listened to their heart? Of course not - this activity is not a paid activity.
Do they ask about the myriad of phone calls and e-mails to arrange for a procedure? Nope.
Do they measure my time with the patient when I go back to see them on the same day? Nope- not paid for.

So what's the motivation for doctors to be doctors? Are we retraining our doctors from care-givers to data providers? What are we losing in turn?

Today, an excellent opinion piece by Daniel Henniger appeared in today's Wall Street Journal. In it, he references an important article by Drs. Christine Cassel and Sachin H Jain published in the June 17th issue of JAMA entitled "Assessing Individual Physician Performance: Does Measurement Suppress Motivation." Cassel and Jain are two shapers of the Pay-for-Performance movement but acknowledge the danger this movement has on physician behavior:

Overstating the value of discrete quality measures has the potential to demotivate and demoralize physicians who appropriately view their job as much more than simply meeting a standardized measure set.

This point cannot be overemphasized.

Doctors are losing their motivation to diagnose in favor of sitting at a computer. Doctors, I also dare say, are losing their skills in favor of sitting at a computer. Clicking buttons has such importance to health care systems that these performance measures are being linked, in part, to doctors' salaries. As a result, young doctors are losing their complex problem solving skills in favor of making sure they click on every result that comes to their inbox, lest they be seen as nonproductive. This, you see, is what matters to employers.

We are reshaping medicine away from the bedside to the computer.

We'd better understand the damage this shift is causing before our young physicians of tomorrow don't know any better.

Monday, July 02, 2012

Shuzan, a Buddhist monk of the tenth century, once held up a bamboo stick before his disciples. "Call this a stick," he bellowed, "and you assert; call this not a stick, and you negate. Now, do not assert or negate, what would you call this stick? Speak! Speak!"

From out the ranks, a young monk ventured forth, grabbed the bamboo, and, breaking it in two, exclaimed to Shuzan, "What is this?"*

Team-based patient care, that is, care involving multiple attending physicians from multiple services, multiple residents under work-hour restrictions, and a compendium of pharmacists, nurse practitioners, social workers, physical therapists and occupational therapists and the like -- seems to be the latest, greatest fad in medical care these days, especially in large health care systems. While there are many advantages in this approach, there is also a disturbing shortcoming that I seem to be observing: something I’ll call dilution of responsibility.

This phenomenon should not be confused with the "hand-off" errors we've heard so much about. Rather, this phenomenon is more insidious. Today, more attending physicians have responsibility for an individual patient at varying times during their inpatient treatment than ever before. For instance, there are ICU attendings, ward/teaching attendings, hospitalist attendings, outpatient attendings (who may or may not want to participate in inpatient care), and specialty attendings - each with their niche of inpatient care.

These days as a consulting physician, for instance, I often wonder after writing my consult that contains recommendations for therapy if I should also write the orders on a patient. In the past, this never happened. Back in earlier times, the senior residents served as the "Commander and Chief" of inpatient care. Attendings were not allowed to enter orders on a patient. That way, the senior resident, in concert with his responsible attending, knew what was and wasn't to happen with a patient. Everyone caring for the patient knew who had ultimate responsibility to make things happen. With our new model of "team-based care" our Commander in Chief is lost. It is becoming increasingly difficult to know if team caregivers are reading my recommendations and deciding to ignore them or just figuring someone else will implement them. How do I, as a “consultant,” know? Too often, omissions of therapy and the rationale for such are not communicated by today’s disparate and tunnel-visioned caregivers. Leadership is not easily assumed when everyone feels they are the leader.

With the trend of larger health systems under growing price pressures, I also see a growing trend to cross-train clinical and technical personnel across disciplines. No where is this more evident than in the cardiac catheterization and electrophysiology laboratories, for instance. From a manpower standpoint, this makes good sense. But we also risk making these clinical and technical personnel slaves to many but masters at none. It is a fine line that is constantly challenged these days: quantity of care over quality of care. Larger health systems with multiple hospitals, each with their separate laboratories amplify these challenges. In such a construct, not only are personnel required to know many areas of expertise, but also the many locations where the same piece of equipment might reside as well. Checklists, in cases like this, can only go so far.

These are the challenges doctors face going forward as physicians ultimately responsible for our patients’ well-being in our new era of team-based care. In many respects, these challenges are not new. But administrators squeezed by cost concerns should also be sensitive to the growing challenges caregivers encounter in this environment.

And doctors, like the young monk who steps forward in the story at the beginning of this post, mustn’t forget how to take the stick.

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.